Provider Demographics
NPI:1720600208
Name:SMITH, GREGORY JAMES DUANE
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES DUANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 N SWAN RD APT 424
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5437
Mailing Address - Country:US
Mailing Address - Phone:925-520-5995
Mailing Address - Fax:
Practice Address - Street 1:1014 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4239
Practice Address - Country:US
Practice Address - Phone:925-520-5995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-6397T1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty